messy, not smelling of roses and a tilted view required

Andrea WilliamsonSouthern Medical Society Presidential Address 2013

Messy, not smelling of roses: and a tilted view

required

Biomedical positivism: graphs, gradients, life expectancy

Qualitative interpretivism: perspectives and explanations

The experience of the interpersonal and relationship

Knowledge claims: some isms

Social determinants of health

“the conditions in which people are born, grow, live, work and age…” (WHO)

People risk markers: age, sex, ethnicity, sexual orientation, education

Place risk markers: geography, community, workplace

Meta-risk marker: SOCIO-ECONOMIC POSITION

*All are interlocked and socially patterned*

Health inequalities

Poverty truth commission video: Isha from Govanhill

“the conditions in which people are born, grow, live, work and age, including the health system” (WHO)

“Health equity through action on the social determinants of health”

=tackling health inequalities

45,000 households applied as homeless, Scotland, 2011-12 42% single men 22% single women 17%single parents (women) 7% single parent (men) 5% couples with children

(Source Shelter Scotland)

Homelessness in Scotland

Refused asylum seekers

‘no recourse to public funds’ Numbers unknown, survey March 2012:

78/112 Rough sleeping Sofa surfing Night shelter and voluntary sector support Right to full NHS care if ever applied for

asylum

(Scottish Refugee Council 2012, 2013)

‘New’ Homelessness

Your experience of working with a person who is homeless?

All people are individuals and have their own storyHowever many people have had the following experiences: Disrupted family life (poverty, abuse,

into care) Poor educational attainment Poverty Experiences of violence Addictions Mental health problems On-going risky relationships

(Source National Mental Health Development Unit 2010)

Chronic homelessness

Mortality X6 risk of death than general

population 1.4 times more likely to die than the

most deprived housed person Drug misuse Circulatory disease Respiratory disease Importance of psychiatric morbidity

(Neilson et al 2011,Morrison 2009)

Housing First video: Brian

Adult attachment Personality disorder Complex trauma

Important concepts for

effective consultations

Impact on Thinking Feeling Behaving

Impulsiveness…self sabotaging…self harm…emotional lability….dissociation...unexplained physical symptoms

Features

Listen to what your emotions tell you when you interact with patients: frustration, anger, disgust, fear

Accept your response is often a reaction to patients psychological function (not always)

Encourage safety: physical, emotional and social: for you and patients

Be very careful of verbal and non verbal leakage (including psychological environments)

How to respond?

Patients respond, feel safe and function better (so you might actually get to addressing health issues)

Professional patient relationships are key to an effective health service

You will waste less emotional energy getting angry, frustrated, upset

Why?

life course approach– attachment– adverse life events– Resilience

Patient at the centre of care Involving wider health and social care

team Snap shot versus the long view Role of the therapeutic alliance

Trust Boundaries Longitudinally over time

Key homelessness health care

concepts

“revolving door” patients in general practice

Serial missed appointments in the NHS

Evaluation of vulnerable women’s addiction clinic in South Glasgow

Research interests

[Barnett, Mercer, Norbury, Watt, Wyke, Guthrie, 2012]

T, mid 40s. She has chronic depression with multiple previous suicide attempts. She suffers from angina and has had an MI in the past. She lives in a flat with her boyfriend. T has recently been deemed fit for work, but is appealing this decision. Money is extremely tight, and she and her boyfriend are currently surviving on his benefits alone. T has suffered from physical, sexual and emotional abuse all her life and her current relationship is no exception. T wants to visit her daughter (whose young child has recently been removed from her care), but can’t afford the coach fare – her partner (not the daughter’s father) won’t pay, as he will not allow T to leave him, even to see her own family. T is waiting for her daughter to pay for the coach ticket. The daughter in turn is waiting for her own benefits to come through. Another daughter is homeless.

[case study extract, Deep End Austerity report 2012]

GPs at the Deep End

Role of health care at its best where its needed most Arrangements and resources

reflecting the epidemiology of multi-morbidity

General practice as the natural hub Importance of serial encounters

Time Relationships

With patients With other professionals in

healthcare Outside health care (social

prescribing and advocacy) Connectedness of care

GPs at the Deep End

Within the health system Relationship work in consultations Relationship work with other

professionals Social prescribing and community

engagement Influencing health policy (research,

teaching and Deep End work)

Being an engaged citizen and advocate for change

Action

Andrea WilliamsonSouthern Medical Society Presidential Address 2013

andrea.williamson@glasgow.ac.uk

Messy, not smelling of roses: and a tilted view

required